U.S. NAVY MEDICINE Vol. 71, No.4 April 1980

U. S. NAVY MEDICINE

April 1980

Contributing Editors

Contributing Editor-in-Chief: CDR E.L. Tay-
lor (MC); Dental Corps: CAPT R.W. Koch
(DC); Education: LT R,E. Bubb (MSC); Oc-
cupational Medicine: CAPT J,J. Bellanca
(MC); Preventive Medicine: CAPT D.F.
Hoeffler (MC); Facilities: LT 0.M. French
(CEC)

POLICY: U.S. Navy Medicine is an official publication
of the Navy Medical Department, published by the Bureau
of Medicine and Surgery. It disseminates to Navy Medical
Department personnel official and professional information
relative 10 medicine, dentistry, and the allied health sci-
ences. Opinions expressed are those of the authors and do
not necessarily represent the official position of the Depart-
ment of the Navy* the Burean of Medicine and Surgery, or
any other governmental department or agency. Trade
names are used for identification only and do not represent
an endorsement by the Department of the Navy or the Bu-
reau of Medicine and Surgery. Although U.S. Navy Medi-
cine may cite or extract from directives, official authority for
action should be obtained, from the cited reference.

DISTRIBUTION: U.S. Navy Medicine is distributed to
active-duty Medical Department personnel via the Standard
Navy Distribution List. The following distribution is author-
ized; one copy for each Medical. Dental, Medical Service,
and Norse Corps Officer, one copy for every 10 enlisted
Medical Department members. Request to increase or de-
crease the number of allotted copies should be forwarded to
U.S. Nayy Medicine via the local command.

CORRESPONDENCE: Al! correspondence should be
addressed to; Editor U.S. Navy Medicine, Department of
the Navy, Bureau of Medicine and Surgery (MED OOlD),
Washington, D.C. 20372. Telephone: (Are* Code 202) 254-
4253. 254-4316. 25M2M; Aatovoo 294-4253, 294-4316. 294-
4214. Contributions from the field are welcome and will he
published as space permits, subject to editing and possible
abridgment.

The issuance of this publication is approved in accordance
with Department of the Navy Publications and Printing
Regulations {NAVEXOS P-35).

U. S. NAVY
MEDICINE

Vol. 71, No. 4
April 1980

NAVMED P-5088

1 From the Surgeon General

2 Department Rounds

Three New Flag Officers

4 Scholar's Scuttlebutt

Servicemen's and Veterans Group Life Insurance

5 Features

On Growing Children— The Child Who Steals
CDR E. Breger. MC, USNR

7 Contact Point Management: How Do You Rate?
LCDR W.F. Leadbeater, MSC, USN
LTH.C. Coffey, MSC, USN

10 The President's Hospital
J.K. Herman

12 Cold Weather Dentistry: A Review
CAPTM.R. Wirthlin, Jr., DC, USN

16 Sticks and Stones Can Break My Bones
S.J. Debtee, Jr.

18 Reserve

An Essential Partner in Naval Readiness
LCDR S.B. Haberkorn, MSC, USNR-R
LCDR E.A. Donahue, MSC, USN

21 Professional

Mesenteric Infarction Following Exercise in a Patient With Sickle

Cell Trait

LCDR S.R. Shackford, MC, USN

LCDR A.L. Herren, MC, USN

CDR J.D. Spencer, MC, USN

24 Immunization Survey in a Military Practice
LCDR W. W. Burns, MC, USN

26 Serendipitous Discovery of Artificial Positive Weil-Felix Reaction
Used in "Private Immunological War"
E.S. Lazowski
S. Matulewicz

28 BUMED SITREP

29 Notes and Announcements

COVER: Blood sample from a patient with sickle cell trait. An article
on page 21 details a fatal episode of mesenteric infarction, a rare but
serious complication of this blood disorder. — National Heart, Lung,
and Blood Institute, National Institutes of Health.

FROM THE SURGEON GENERAL

Involvement Requires Communication

From my vantage point, I have had
the opportunity to observe the
operations of the Navy Medical
Department in some detail. Earlier
suspicions have been confirmed
that, although communication has
been emphasized and indeed im-
proved, misperceptions and misun-
derstandings continue to occur. 1
would like to share with you my
thoughts in one area that has been
of long duration, seldom verbalized,
but ever present and pervasive in its
detrimental effects on our mission.

The Bureau of Medicine and Sur-
gery is our headquarters activity for
Navy medicine. Yet I find that ex-
cept for those who have been as-
signed to BUMED, very few of our
people share a common and ac-
curate knowledge about its purpose
and function. The Bureau is com-
prised of some 400 Navy military
members and civilian employees
charged with the responsibility for
assisting the Chief of the Bureau of
Medicine and Surgery in the admin-
istration and operation of the Navy
Medical Department. This includes
policy development, planning and
programming for medical support to
the operating forces, health care
delivery to dependents and other
authorized beneficiaries, and the
professional development and train-
ing of Navy Medical Department
members, both active and reserve.

Recognizing the need for a more
functional and responsive organiza-
tion, the Bureau has taken several
steps in the past two years to

enhance our capability to perform
the mission assigned. In 1978, the
Office of the Surgeon General (OP-
093) was established in the Office of
the Chief of Naval Operations. This
office provides Navy medicine with
a voice in the highest echelons of
command to assure proper support
for our programs and requirements.

In 1979, the Bureau of Medicine
and Surgery was reorganized. The
more systematic and effective man-
agement of our affairs that this step
affords is clearly evident. Our
ability to respond to high level
tasking has been tested and proved
successful. Despite much publicity
and discussion, the new organiza-
tion has been limited in its ability to
provide the internal support to the
Navy Medical Department that is so

vital to the accomplishment of our
mission. Each of us must under-
stand that the Bureau, like our other
medical establishments, is a service
organization. Policy must be de-
veloped, utilizing as a data base a
full understanding of the current
requirements and problems rather
than unfounded or fragmented in-
formation. Plans, programs, and
developments must address the
pertinent issues of both the present
and future.

In this regard, you are the eyes
and ears, the sensory mechanism,
for the Bureau. Communications
must flow to us here in Washington
so we may evaluate and react to
worthwhile information. AH too
often it is erroneously perceived
that BUMED is the mystical body
on high that dictates to the medical
establishment. We have sought to
dispel this through a variety of
means, but the real solution lies in
your direct involvement through
correspondence and communication
with those who serve you at this
level. The keys to our success are
frequent input and valid feedback.
Participative management is the
critical element. Together, we can
and will achieve our goal of quality
health care to all of our beneficiar-

W.P. ARENTZEN

Vice Admiral, Medical Corps

United States Navy

Volume 71, April 1980

DEPARTMENT ROUNDS

Three New Flag Officers

The Medical Department has three
new flag officers, two from the
Medical Corps and one from the
Dental Corps.

RADM-selectee Lewis H. Seaton
<MC), commander of the Naval Sub-
marine Medical Center, Groton,
Conn, since 1977, is a Pennsylvania
native. He attended the University
of Pittsburgh and received his M.D.
degree in 1955.

Dr. Seaton was commissioned
and reported to Naval Hospital, San
Diego, Calif, for an internship,
which he completed in 1956. After
receiving training in radiobiology at
Reed College and several Federal
nuclear facilities, he participated in
nuclear weapons testing at the
Nevada Test Site in 1957.

Dr. Seaton graduated from Deep
Sea Diving School and Submarine
School in 1957. His first submarine
duty was as squadron medical offi-
cer of Submarine Squadron Five.
He served on the USS Seadragon
and was aboard during its historic
polar cruise in August 1960. As-
signed to the Navy's first nuclear
powered aircraft carrier, USS
Enterprise, he returned to subma-
rine duty in 1963 and served succes-
sive tours as medical officer of Sub-
marine Flotilla Six and Submarine
Squadron Sixteen.

Dr. Seaton completed his oph-
thalmology residency at NNMC
Bethesda, Md. in 1967 and served
as chief, Ophthalmology Service
and Director of Interns at the Naval
Hospital, Jacksonville, Fla. In 1973
he returned to NNMC as Chairman,
Department of Ophthalmology.

He is a diplomate of the American
Board of Ophthalmology, a fellow of

the American College of Surgeons,
and the American Academy of Oph-
thalmology and Otolaryngology. He
has held several offices in the Soci-
ety of Military Ophthalmologists.
He has been Associate Professor of
Ophthalmology, George Washing-
ton University and Associate Pro-
fessor of Surgery (Ophthalmology),
USUHS.

Dr. Seaton' s military awards
include the Meritorious Service
Medal, Navy Unit Commendation
Ribbon, Navy Expeditionary Medal,
Armed Forces Expeditionary Med-
al, and the National Defense Medal.

RADM-selectee William M. Mc-
Dermott, Jr. (MC), Commander of
NRMC Jacksonville, Fla., was born
24 Sept 1929 in Fitchburg, Mass.
He graduated from Tufts University
with a B.S. in biology and chemis-
try. He received an M.S. degree in

CAPT Seaton

CAPT McDermott

physiology from Tufts University
and was awarded his M.D. degree
from Tufts University School of
Medicine. He then completed his
pediatric internship at the New
England Medical Center, Boston,
Mass.

Dr. McDermott entered the Navy
in 1963. He has served in various
positions including Chief, Pediatric
Service, Naval Hospital, Camp
Lejeune, N.C. from 1965 to 1967.
He then completed residency train-
ing in anesthesiology at NNMC
Bethesda, Md. From 1969 to 1970,
he was Director of Clinical Services
and Commanding Officer, 3rd Med-
ical Battalion, 3rd Marine Division,
FMF. He then reported to NRMC
Portsmouth, Va. as Chairman, De-
partment of Anesthesiology, where
he remained until 1973.

Dr. McDermott became Associate
Director of the Education and Train-
ing Branch at BUMED and was then
assigned as Deputy Special Assist-
ant to the Surgeon General in 1975.

U.S. Navy Medicine

The following year he became
Special Assistant to the Surgeon
General. Dr. McDermott was then
assigned as Director of Clinical Ser-
vices, NRMC San Diego, Calif., and
in 1978 assumed command of
NRMC Jacksonville, Fla.

Dr. McDermott is a diplomate of
the American Board of Anesthesiol-
ogy and a diplomate of the Ameri-
can Board of Medical Examiners.
He was a member of the Lambert-
Kingsley Honor Society, Tufts Uni-
versity.

He holds the Bronze Star with
Combat V, Meritorious Service
Medal, National Defense Medal,
Vietnam Service Medal, and Viet-
nam Campaign Medal.

RADM-selectee Thomas W. Mc-
Kcan (DC), Commander of NRDC
Pensacola, Fla., was born 18 May
1928 in Adams County, Ind. He
graduated from Indiana University
in 1953 with a D.D.S. degree. He
was commissioned as ensign in the
Navy Reserve in 1949 and came on

■-»W:'-=-

CAPTMcKean

active duty during his senior year of
dental school.

Dr. McKean's first assignment
was at the Naval Training Center,
Great Lakes, 111. followed by a tour
aboard USS Randall as dental of-
ficer. He was then stationed at the
Naval Academy, Annapolis, Md.
until 1959, when he went to Ber-
muda with FASRON III.

In 1962, Dr. McKean received
postgraduate training at NNMC
Bethesda, Md. He had two more
years of oral surgery residency at
the Naval Hospital, Great Lakes, 111.
From 1966 to 1968, he served
aboard USS America as dental of-
ficer. His next assignment was at
the Naval Hospital, Orlando, Fla.,
where he was Chief of Oral Surgery.

In 1970, Dr. McKean returned to
Great Lakes, 111., where he served
as Chief of the Dental Service at the
Naval Regional Medical Center. In
1974, he became Chief of the Dental
Service, NRMC Oakland, Calif, and
assumed his present position at
NRDC Pensacola, Fla. in 1978.

Dr. McKean is certified by the
American Board of Oral Surgery, is
a fellow of the International Asso-
ciation of Oral Surgeons, a member
of the American Association of Oral
and Maxillofacial Surgeons, West-
ern Society of Oral and Maxillofacial
Surgeons, American Dental Asso-
ciation, American Society of Dental
Anesthesiology, Florida Society of
Oral Surgery, a fellow of the Inter-
national College of Dentistry, and a
fellow of the American Dental Soci-
ety of Anesthesiology.

He holds the National Defense
Medal with bronze star, Naval Oc-
cupational Medal, Vietnam Cam-
paign Medal with bronze star, and
the Vietnamese Presidential Unit
Citation. □

Volume 71, April 1980

SCHOLAR'S SCUTTLEBUTT

Servicemen's and Veterans
Group Life Insurance

Servicemen's Group Life Insurance (SGLI) offers mil-
itary personnel up to $20,000 of group coverage, term
life insurance, with no cash, loan, paid-up, or extended
insurance value. The $3.00 monthly premium for this
coverage is automatically deducted from your pay-
check.

You may decline SGLI coverage, or you may reduce
your coverage to $15,000, $10,000 or $5,000 with corre-
sponding reductions in premiums to $2.25, $1.50 and
$0.75.

To decline or reduce SGLI coverage, you must fill out
VA Form 29-8286 and file it with the disbursing officer
at your active duty or active-duty-for training (ACDU-
TRA) station.

Members of the Naval Reserve who report to
ACDUTRA for more than 30 days automatically receive
the $20,000 SGLI coverage. Since Armed Forces Health
Professions Scholarship Program students are required
by law to spend 45 days each year on ACDUTRA, they
are automatically covered under SGLI during their
ACDUTRA tour and 120 days beyond. Naval Reserve
students in other programs, such as the Dental Student
19251 Program, are also eligible if their ACDUTRA
lasts more than 30 days.

After release from ACDUTRA, your SGLI coverage
continues for 120 days without any premium charge.
You may then extend your coverage by converting to
Veterans Group Life Insurance (VGLI). The amount of
coverage and the premiums are the same as SGLI, but
the method of premium payment is different; also, the
length of participation is limited to five years and is
nonrenewable.

Students cannot apply for VGLI unless they were
previously insured under SGLI. Also, the VGLI policy
cannot be for an amount greater than the SGLI cover-
age. After release from ACDUTRA, you will have 120
days to convert to VGLI without evidence of insurabil-
ity. Once these 120 days have elapsed, you have an
additional year in which to apply for VGLI, but evidence
of insurability may be required.

HOW TO APPLY FOR VGLI

Within 120 days of release from ACDUTRA:

1) Obtain VA Form 29-8714 {Application for Veter-
ans Group Life Insurance) from any VA office or from
OSGLI, 212 Washington St., Newark, N.J. 07102.

2) Mail the complete VA form along with a fully en-
dorsed copy of your ACDUTRA orders and $3.00 to
OSGLI. Upon approval of your application, OSGLI will
send you a certificate and supply of monthly premium
payment cards. Your subsequent monthly payments
will not come due until one month after the 120-day
"free premium" period. Arrangements may also be
made to pay quarterly, semiannually, or annually.

Within one year after 120 days have elapsed:

1) Obtain VA Form 29-8714-2 (Application for Veter-
ans Group Life Insurance — Veterans Separated More
Than 120 Days) from any VA office or from OSGLI.

2) Follow the same instructions given above. The
basic difference between the two forms is inclusion of a
health information section on VA 29-8714-2. OSGLI
may also request additional medical information or fur-
ther proof of insurability if warranted by your answers
in the health information section.

FUTURE ACDUTRA AND ACTIVE DUTY

Although you may carry both VGLI and SGLI, the
combined amount of coverage cannot exceed $20,000.
When you report for each tour of ACDUTRA, you are
again automatically covered under SGLI and $3.00 per
month will be deducted from your pay. If you wish to
stop this deduction, upon reporting for ACDUTRA you
must immediately decline SGLI in writing on VA Form
29-8286. Either the personnel office or the disbursing
office at your ACDUTRA station will have this form.

You may not cancel your VGLI to take advantage of
the 120-day SGLI "free premium" period each time you
report for ACDUTRA. However, once you report for
extended active duty after graduation, you should
cancel your VGLI policy and take SGLI coverage. You
will again become eligible for the VGLI five-year non-
renewable policy after your release from active duty.

bl*\ii\

U.S. Navy Medicine

On Growing Children

The Child Who Steals

CDR Eli Breger, MC, USNR

"To make your children capable of
honesty is the beginning of educa-
tion." Raskin

It has long been recognized that the
growing child has a natural desire to
take and accumulate objects which
he wants and have value to him.
Parents respond to this behavior
with social training regarding prop-
erty rights. With a child's natural
development and maturity there
develops a predictable set of inner
controls to curb these impulses.
This "inner harness" cultivates
that portion of his mind called the
"conscience" and with time a
moral code develops by which to
live.

Failures in the development of
this mental mechanism are common
and well known to parents and
others dealing with children. That it
is not more widely apparent reflects
parental hesitation to openly dis-
cuss this socially unacceptable be-
havior and their attempt to work it
out privately. Stealing in childhood

Dr. Breger is Chief of the Psychiatry Ser-
vice at the Naval Hospital Beaufort, S.C.
29902. Copyright 1980 Eli Breger, M.D. All
rights reserved. May be reprinted or repro-
duced within the Navy for nonprofit type
educational purposes in keeping with the fair
use doctrine.

can be selective or indiscriminate,
occasional or habitual, and perpe-
trated alone or in a group. Ordinar-
ily, stealing in childhood is not
serious when it occurs while the
child is acquiring the concept of
property rights. If judiciously
handled it has no serious conse-
quence. However, as with all
"everyday problems of the every-
day child," inadequate or inappro-
priate management may lead to the
symptom continuing and it then be-
comes increasingly difficult to
manage.

An effective and intelligent ap-
proach depends on knowledge of
the psychological issues involved.
The mechanisms leading to stealing
in childhood are varied and in any
given child more than one mecha-
nism can be additively at work.

Developing a Sense of
Property Rights

To the very young, all the world,
including himself, belongs to adults
and things that come to him are
given by others. With age and in-
creasing motility he learns he can
reach out and take things. This
brings forth parental responses as
to what can and cannot be taken. By
age two a child is aware of what he
can take based on these parental
responses. It takes considerably
more training by word as well as by

example to firmly establish this con-
cept. Most often it is well consoli-
dated when a child starts school,
although occasional breakdowns
may occur.

Although economically and so-
cially disadvantaged families may
have the highest of moral and
ethical standards, children in such
environments do steal more often.
Crowded living arrangements, lack
of privacy, and a need to share
clothing and belongings blur clear
boundaries between people and
things and markedly hinder the de-
velopment of a sense of property
rights. Additionally, the hardships
and burdens of meeting the most
essential needs of family life can
limit adequate attention being
focused on the development of this
concept. Where possessions are
scarce and joys few, the desire in a
child to take something not belong-
ing to him can be very great indeed.
Such environments sometimes con-
tain criminal behavior within the
parents themselves which the child
adopts through modelling. Even if
this is absent, when parents are
overburdened, the child often is
neglected. He may readily fall into a
"street gang" subculture from
which he receives a sense of identity
denied him at home. He steals as
part of that culture. Such children
are well known to the courts which

Volume 71, April 1980

attempt to help them. Often this
necessitates removing them from
their environments and placing
them in training schools.

Within the more advantaged,
educated, and economically stable
population, ineffective training may
also exist. Unwitting parents insist
on their child sharing his prized
possessions with siblings so as not
to be selfish and thereby discourage
his developing a sense of property.
Should the child see his parent lack
respect for the boundaries and
properties of others he may follow
suit. A parent sets a bad example by
accepting incorrect change in one's
favor, bringing home pencils and
clips from the office for personal
use, opening letters addressed to
the children, searching a child's
room, or going through trousers or
purses to confiscate money. Parents
may be quite inconsistent when
they instruct a child to respect
money belonging to others yet,
when he asks for some, they in-
struct him to go to their purses and
take it.

Another common occurrence is a
child taking something in a store.
The parent finds this cute and
condones it or becomes so embar-
rassed that she covers up by buy-
ing the item. Parents often lose
the opportunity to focus on "what is
thine and what is mine" by admon-
ishing a child for taking something
only in terms of "God will punish
you . " In a society which stimulates
children's desires to possess many
material items it is impressive how
frequently parents neglect to bolster
money management by providing
the child with allowances and op-
portunities to earn money.

The Role of Peers

Despite adequate training, chil-
dren frequently begin to steal
because of personal emotional prob-
lems related to feelings of inade-

quacy in dealing with their own age
group. The desire and need for
friendship are powerful forces
throughout all of childhood. Fre-
quently children will steal money to
splurge on items for their friends in
a desperate effort to obtain accept-
ance, approval, and prestige. Most
commonly, this occurs in a child
with low self-esteem, but occasion-
ally a confident child may so react
when he is in surroundings with
wealthier children. The insecure
youngster brags about what he
owns but then has to come up with it
to retain his reputation.

Not infrequently, as part of an
initiation to gain acceptance into a
group, peers will dare a child to
steal to prove his courage. This is
one of the factors present in shop-
lifting by teenage girls and car theft
by adolescent boys. If they aren't
proving something to their friends
they are proving their daring to
themselves.

There are children with strong
feelings of inferiority based on
realistic or imagined weaknesses
who may be coerced or tormented
by stronger and more aggressive
children to steal for them, or else
pay the price in physical assault.

Understandably, to effectively
help these children, much more is
involved than teaching them right
from wrong and developing a sense
of property rights. In essence, we
try to help the child develop greater
confidence, support his fragile self-
esteem, and help him learn to love
himself.

The Role of Family Relationships

Stealing frequently reflects a
child's vengeful feelings against his
parents. He feels they reject him,
neglect him, treat him unjustly, or
deal with him in an excessively
authoritative, punitive, or abusive
manner. He steals not for the
pleasure of what he will obtain,

which is often insignificant in and of
itself, but rather because it will
annoy his parents and satisfy his
feelings for revenge. Such behavior
is likely to spill over into other anti-
authoritative directions. It will not
be of an open and defiant type but
more usually it will be in the direc-
tion of concealment or passive re-
sistance. Corrective action depends
on careful analysis of the family
imbalance. This should include
understanding the child's angry
feelings, realistically normalizing
his environmental condition, and
enhancing a better understanding
and love among family members.

Childhood stealing commonly re-
flects compensation for feelings of
rejection and lack of love. Here the
thrust is not for revenge. It is an
unconscious filling up of oneself
materially for the absence of paren-
tal acceptance and affection. The
urge is strong and compulsive; the
child feels guilty and yet does not
know why he steals. Only intensive
therapy can help such children find
a way out of their grave emotional
conflict and enable them to under-
stand the connection between their
compulsive actions and their feel-
ings.

There are children who have
never established a sense of basic
trust and security with their par-
ents. They lack feelings of affection,
are undemonstrative and, along
with this, lack feelings of shame and
responsibility. These are extremely
damaged children who very often
have had losses of loved ones or
separation from parenting individ-
uals early in their lives. Without
this basic love tie, moral and ethical
behavior is seriously compromised.
These children frequently steal
repeatedly, show truancy, often
wander aimlessly, and appear des-
tined to a life of crime and delin-
quency. Aiding such children in-
volves early intervention with care-
ful and skillful environmental plan-

U.S. Navy Medicine

ning aimed toward his developing a
love tie with some meaningful indi-
vidual. When treatment is instituted
later in life, the outlook is generally
quite poor.

The Neurologically Handicapped

Children who are mentally re-
tarded and/or brain damaged are
more prone to steal. It is not the
retardation or neurologic impair-
ment which causes stealing. Rather
it is because these factors have seri-
ously impaired their intellectual
understanding of property rights
and their weak neurologic system
makes it more difficult for them to
develop self-control. Most children
with these problems do not steal
because they have had adequate
training. Their parents had to work
on it more energetically and per-
sistently than for a normal child.

Teenage Regression

Adolescents who previously con-
trolled their stealing desires may
show a tendency to break down and
steal again during the early stages
of puberty. These incidents are
usually of a passing nature and re-
spond to support, reeducation, and
time. A relatively new phenome-
non relates to widespread drug
use among teenagers requiring
funds to support the habit. This has
increased stealing by adolescents to
epidemic proportions and is a prob-
lem requiring the attention and co-
operation of many segments of
society.

Be mindful that even under the
variety of circumstances described
above it is only the occasional child
who steals habitually. The symptom
should be viewed as an individual
and specific reaction to the child's
unique and complex life situation.

"The parent's life is the child's
copybook." Partridge □

Contact Point Management:
How Do You Rate?

LCDR W.F. Leadbeater, MSC, USN
LT H.C. Coffey, MSC, USN

A mother of three children ap-
proached the Medical Records Of-
fice to request the clinical record for
her oldest daughter, who had just
received a walk-in pediatric appoint-
ment. The records clerk, after re-
trieving the record, noticed that it
was the child's birthday. She quick-
ly summoned two other people in
the office, and they sang "Happy
Birthday" to her. The child, as
feverish as she was, broke into
smiles. Other people in the area ap-
plauded, and work went on as
usual.

At the same medical center, a
mother of two very young children
was in tears because she was being
denied treatment. She had arrived
five minutes late for her appoint-
ment to have a pap smear retaken.
Although she had travelled an hour
from home, leaving her newborn
daughter and 16-month-old son with
a babysitter, and although there
was only one other patient waiting
to be seen, the 5-minute rule was
going to be enforced!

These two incidents are actual.
They could be repeated at any
medical facility on any day. Al-
though they are extreme examples
of how patients can be treated, they
demonstrate the effect that a staff
member can have on a person enter-
ing our health care system. Choos-
ing to work in a service organization
lays the responsibility of creating a
positive environment on each of us.
It is this environment that often de-

termines the patient's perception of
the quality of care received. As
health care managers, we have the
obligation to create and maintain an
atmosphere of service and coopera-
tion for both staff and patients. This
is one goal of Contact Point Man-
agement (CPM).

An Educational Process

Contact Point Management is the
conscious effort of all personnel in
medical and dental facilities to give
unconditional positive response to
each person who comes in contact
with the hospital or clinic. It is a
process of training each staff mem-
ber in the techniques of delivering
optimal service, free from bias
created by preformed attitudes and
prejudgment based on our previous
experiences. It is educating the staff
to a new level of awareness of their
individual importance and their
interpersonal influence. It allows
each staff member to accept respon-
sibility and develop his full poten-
tial for providing service. CPM
involves learning how to listen, how
to seek out obvious and hidden
problems; it involves responding to
requests for assistance from other
staff members; and it involves

LCDR Leadbeater and LT Coffey are in-
structors at the Naval School of Health Sci-
ences, Bethesda, Md. 20014.

Volume 71, April 1980

creating an enjoyable environment
to deliver and receive care.

It would seem that this process
could mean occasionally submitting
to the unreasonable demands of the
clinic abuser. However, one should
no more take this approach than a
parent should reward a child for
misbehavior. CPM trains the staff
how to deal with the abuser in a
compassionate, firm, and respectful
manner.

How to Begin

A good place to begin with CPM
is to determine the status quo of
your own service. A questionnaire
can be developed by using Table 1
as a guideline. The questionnaire
would be completed by you and
your staff, other staff members who
interact with your service, and by
the patients who use your service. A
careful analysis of the results
should indicate where your service
is strong and where it could use
contact point training. A question-
naire and analysis sheet designed to
accomplish this have been de-
veloped by the staff at the Naval
School of Health Sciences and are
available upon request. Just write
to: Naval School of Health Sciences,
Bethesda, Md. 20014.

What's Next?

Once you and your staff have
identified general areas that require
improvement, you can begin to
design an education and training
program. There are two sources of
assistance for this part of your pro-
gram — the Health Sciences Educa-
tion and Training Command
(HSETC) at Bethesda, Md., and the
Education and Training Service at
your own command. Table 2 lists
areas that might be included in your
program.

Remember that training a person
to perform a task, which is an im-

portant part of CPM, is only a part
of the process. Even more important
is the education process. Your staff
should learn how to accept responsi-
bility, how to think and be innova-
tive, how to implement policy, and
above all, they should learn the
importance of the role they play in
the health care delivery system. A
positive attitude of self-worth and
importance will help your staff

develop the ability and skills neces-
sary to respond effectively to people
as they pass through our hospitals
and clinics. For this reason, advice
from professional educators is
highly encouraged.

The Real Work Begins

We have now left the initial
stages of the CPM program. The

TABLE 1 . Criteria to Evaluate Contact Point Efficiency

Clinic Environment

» Easy to find and well identified

• Pleasant decor

• Clean

• Promotes confidentiality

• Free of odors

• Comfortable

Staff Appearance

• Well groomed

• Professionally dressed

• Excellent posture

Greeting the Patient

• Prompt recognition

• Pleasant greeting

• Expeditious telephone response

• Correctly addresses patients

• Uses the name of the patient

• Correct messages to patients

Communications

• Staff listens

• Understands patient problems

• Deals with foreign speaking patients

• Timely response to patient inquiries

• Correct information about appointment delays

Information Giving

• Familiarity with departmental procedures

• Familiarity with hospital policy and procedures

• Provides correct directions

Staff Attitude

• Willingness to help patients and staff

• Cooperation with other services

• Enjoys helping patients

U.S. Navy Medicine

TABLE 2. Contact Point Personnel Training Program

Introduction

• Goals and objectives of CPM

• Definition of CPM

• Impact of CPM

• Understanding the whole program

Human Relations

• Importance of the individual

• Power of positive influence

(• Understanding the patient
Communications Skill Development

• The art of listening

• How to ask questions

• Nondirective interviews

• Clear transfer of ideas

• Nonverbal communications

• Effective use of the telephone

Contact Point Responsiveness

• Identifying and dealing with difficult situations

• Standards of courtesy and respect

• Accepting responsibility

• Manual of information

• Manual of procedures

• Proper use of policy

Note: This represents only a brief summary of what some of the topics
could be and is not a complete program.

monitoring, reevaluation, feedback,
and education process never slows
down. It is the unrelenting deter-
mination of the manager that will
make this program a success. The
monitoring of the program can be
done in several ways. Keeping track
of compliments, complaints, patient
satisfaction card, and impromptu
discussions with patients are only a
few. After a specific period of time,
a reevaluation of the program could
be done by reissuing the question-
naires. This would give you a basis
of comparison and a measure of
success. Very important to this
whole process is the communica-
tions and feedback you have with

your staff. There is no room for
secrets here. Being honest and
having open channels of communi-
cation will usually guarantee suc-
cess. Along the same lines, the
education process is continual.
Whether this takes the form of
classroom sessions, seminars, or
one-on-one discussions does not
matter. Contact Point Management
takes a good deal of effort and con-
sumes much of your valuable time,
but so does anything worthwhile.
Remember, without some pain,
there is no gain. Once you get
started with the program, you will
wonder how you ever did without it.
So try it, you'll like it I □

Volume 71, April 1980

National Naval Medical Center, Bethesda, Md.

The President's Hospital

Franklin D . Roosevelt — lawyer, pol-
itician. Assistant Secretary of the
Navy, Governor, President, and
one-time architect. History has
much to say about our 32nd Presi-
dent, but few realize that FDR's
taste in architecture directly influ-
enced the design of a prominent
government building.

Tradition says it was a trip to Lin-
coln, Neb., that sparked Roosevelt's
creative genius. Nebraska's State
Capitol building, unlike the domed
structures of the other States, fea-
tured a multistoried tower with at-
tached two-story wings. "Someday,
I will build a government building

like that," FDR was quoted as say-
ing. Undoubtedly, members of his
official entourage sensed that this
was not an idle comment.

On 13 Dec 1937, Roosevelt
scrawled the design of the proposed
Naval Medical Center on a piece of
White House letterhead. The presi-
dential wish became the architects'
and builders' command.

It was the same with the site for
the new complex. From his open
car, FDR chose a suburban Mary-
land farm as the location for his new
naval hospital.

On 29 June 1939, ground was
broken, and on Armistice Day one

year later, the President laid the
cornerstone. It was on BUMED's
centennial birthday, 31 Aug 1942,
that Roosevelt dedicated the com-
pleted hospital.

The intervening years have
brought the building both praise
and criticism, the positive for its
stylishly modern edifice and the
negative for its serious functional
deficiencies.

Even though FDR's hospital has
served the Navy well for almost 40
years, building design is no longer
determined by presidential whim.
The new NNMC building, sched-
uled to open this year, was left to
the pros. — JKHD

10

U.S. Navy Medicine

/

3

®

•D

£
X l

lij o

i5

bi

X

1-

I — I Tl '

pMHMHbr

L.

j

(Top): The President's plan for the proposed Naval Medical
Center. (Middle): FDR chooses the site — a cabbage field on a
suburban Maryland farm. (Bottom): NNMC's Lake Eleanor
had its origin in this rustic springhouse. (Right): President
Roosevelt mixes mortar for the cornerstone on Armistice Day,
1940.

Volume 71, April 1980

a

Cold Weather Dentistry: A Review

CAPT M.R. Wirthlin, Jr., DC, USN

Cold weather medicine is one aspect
of fleet operations for which there
has been little dental research and
for which there may be little experi-
ence in the military forces.

Cold exposure and injury may
produce specific categories of cas-
ualties such as frostbite and hypo-
thermia and their sequelae or in-
juries related to cold operations
such as skiing accidents. The emer-
gency care trauma and wounds may
be affected by management prob-
lems in the cold; casualty evacua-
tion may require special prepared-
ness. There may also be special
problems related to dental health
maintenance in cold weather opera-
tions. The purpose of this review is
to gather together the experiences
of previous cold weather dentistry
reports.

Early Experiences

Dr. R.G. Frazier was a physician
who accompanied Admiral Byrd to
Antarctica in 1939. Frazier' s narra-
tive account(7) of the effects of cold
was alarming. He stated, "The
most usual and most painful malady
encountered was toothache. All
devitalized and carious teeth be-
came painful and had to be ex-
tracted. As soon as cold air was
brought in contact with these dis-

Dr. Wirthlin is Commanding Officer at the
Naval Dental Research Institute, Great
Lakes, 111. 60088.

eased teeth, the pain became un-
bearable." His account of the
effects of cold further described
fillings contracting and falling out
or leaking, resulting in decay, tooth
extractions, and the need to devise
an emergency filling material. The
only dental equipment in his medi-
cal supplies were two forceps and
two elevators.

LT Jesse E. Owens, DC, USN,
described experiences in dental
care aboard an icebreaker and
ashore in cold weather. (2) His
review of seven emergency cases of
toothache after cold exposure led to
the conclusion that all were the re-
sult of previous carious exposure of
the dental pulp. The cold was
thought to be an irritant which
made dormant conditions exacer-
bate or which brought attention to
symptoms previously ignored.
Based on his experiences ashore at
Little America for Operation Hi
Jump in 1947, Owens recommended
a heated shelter and that the
dentist be handy with carpenter's
tools to insure a suitable facility for
dental services. Dr. Owens had to
build a dental chair out of packing
crates and operate in a tent. He
cautioned that anesthetic solutions
in carpules might freeze and force
the rubber stoppers out or result in
leakage and possible contamina-
tion. He related that tests at the
Naval Medical Research Institute
showed no decomposition of other
frozen dental medicaments and

materials recovered from Thule,
Greenland in 1947.

Duncan (J) related his experi-
ences in the Antarctic on South
Georgia Island in 1953 as requiring
much improvisation, but that the 18
months provided unforgettable sat-
isfaction.

LT David Knoedler, DC, USN,
was the first Navy dental officer
volunteer for Deep Freeze I in
Antarctica. He wintered-over at
McMurdo Sound from December
1955 until February 1957. Dr.
Knoedler had to pioneer the setting
up of the dental facility and care for
the 92 men he accompanied in the
wintering-over party. All but two of
the group sought dental care, and
about 35 percent of the group were
under treatment in an average
month. It was not possible, because
of limited time, to prepare the party
to a high level of dental health
before deployment. Dr. Knoedler
did find instances of restorations
falling out and complaints of tooth-
ache due to inhalation of cold air.
These were found to be the result of
previous secondary decay or deep
restorations without adequate in-
sulating bases. As a result of Dr.
Knoedler's professional care, these
problems were corrected with rou-
tine dental treatment. Gingival dis-
orders also responded well to
debridement and improved hy-
giene. Hypersensitive cervical
dentin was a common complaint,
but it responded to routine care.

12

U.S. Navy Medicine

LT Owens examines a patient in a "dental chair" made from a packing crate at
Little America in 1947. Just to the patient's left is a stovepipe "cuspidor" sunk into
the snow. Recording Dr. Owens' findings is DTI James Welch, USN,

Contrary to previous reports, oral
hygiene was found to be good. Also,
experiences did not confirm
Frazier's accounts of shock follow-
ing injection of local anesthetics
which contained epinephrine. The
only unusually high incidence den-
tal care problems reported involved
10 cases of alveolar osteitis follow-
ing 44 extractions and for which the
cause was undetermined. (4)

The field dental equipment used
was found adequate, but with time
there was difficulty adjusting the
dental chair headrest and the x-ray
machine broke irreparably in mid-
winter. (5)

Subsequent dental support was
provided for in a more organized
and planned manner with the co-
ordination of CAPT William R.
Stanmeyer, DC, USN. (6) LT Robert
J. Adams, DC, USNR, was ordered
to duty sufficiently in advance of

deployment to be carefully indoctri-
nated and to prepare the wintering-
over party to an "essentially com-
plete" category of dental health
maintenance. CAPT Stanmeyer was
also able to give dental first aid
courses to the medical officers who
would go to remote antarctic bases.
Dr. Adams helped build the
dental facility at Little America and
cared for the party that wintered-
over. (7) Subsequent reports (8-14)
revealed that dental care was gener-
ally most similar to the practice
encountered at a regular dental
facility. Efforts were directed to-
ward improving the facility, install-
ing new equipment, and coordinat-
ing the supplies and spare parts
needed. Eventually, the dental offi-
cers obtained the assistance of Navy
dental technicians. A commonly re-
ported problem was drainage from
the dental operatory sink and

cuspidor by gravity to the outside of
the building upon the ground. Ice
would gradually build up and plug
the drain. Unplugging the drain re-
quired considerable effort with an
axe and blowtorch in the dark at
-40° F.

At the Pole Station there were oc-
casional dental problems requiring
tooth extraction by medical person-
nel. Some of these events were oc-
casioned by lack of predeployment
dental preparation in last-minute
volunteers. (10) Naval instructions
required that applicants for Opera-
tion Deep Freeze had to be, at a
minimum, in a Dental Class 2
status. This allowed the dental
officer to prepare them to Dental
Class I status before deployment.
Such effort paid off with minimum
problems for those at remote sta-
tions. (11)

The dental officer's daily routine
and many collateral duties did not
leave much time for research pro-
jects, and the duties of the winter-
ing-over party, especially during
the busy summer construction
period, left few men available for
research subjects. Nevertheless, a
number of investigations were at-
tempted and reported during the
International Geophysical Year (1
July 1957-31 Dec 1958) and a short
time afterward.

Reports indicated two to three
times as many sensitive teeth with-
out insulating bases compared to
those with bases. Small, deep fill-
ings caused more problems than
shallow, extensive ones. Fractured
fillings and teeth most often fol-
lowed a sequence of exposure to the
cold, entering the rewarming area,
drinking hot coffee, and biting on a
hard roll or candy bar. (15) No dif-
ferences in recurrent decay between
inside and outside workers were
detected. Therefore, differences in
the coefficient of expansion of teeth
and restorative materials were dis-
counted as being significant. (16)

Volume 71, April 1980

13

The temperatures measured on
teeth ranged from 86° to 91° F in-
doors, but dropped to a 35° to 59° F
range after 60 minutes in the cold.
This was thought to be due to the
increased mouthbreathing of cold,
low-humidity air with exertion. Acid
production after holding a 20 per-
cent glucose solution in the mouth
for one minute was demonstrated
by decreases in mean dental plaque
pH from 6.44 to 6.02. This effect
was not found after 75 minutes ex-
posure to the cold.(/7) Also, lacto-
baciltus counts of saliva samples
dropped profoundly after the cold
exposure. (17, 18, 19) Streptococcus
salivarius counts varied inversely
with lactobacillus counts. (19) Syn-
der caries activity tests were re-
ported more often positive for in-
door workers than outdoor workers
in 1966.(20) However, in 1971,
there was no indoor/outdoor differ-
ence, but a drop in all workers with
time was noted. (19) The implica-
tions of this were that the metabolic
activity of microorganisms was in-
hibited by the cold, and this might
affect tooth decay. No clinical dif-
ferences in dental caries attack
rates were ever documented to sub-
stantiate the hypothesis.

Specimens of saliva collected
after prolonged residence in the
Antarctic were found to have an in-
crease of protein, tyrosine, and
tryptophan, (21) No definite en-
vironmental effects on dental calcu-
lus formation rate were noted. (22,
23)

Monthly checks of cleanliness of
the teeth by the dental officer, along
with brushing instructions, resulted
in an increase from 29 to 79 percent
of the men being rated as "good."
However, the proportion of those
rated "poor" did not change;
neither did a control group which
did not get repeated exams and in-
structions. (24) The results of
monthly exams and comments on
hygiene by the dental officer were a

significant improvement over the
number of inflamed gingival areas
and reduced intensity of inflamma-
tion. (25) It was especially note-
worthy that not a single case of Vin-
cent's infection developed during
the wintering-over. Of four cases
treated, all were in the acute stage
when the patients arrived in the
Antarctic. (25) A double-blind trial
of an experimental dentifrice did
not show any improved effect over
placebo, but again it was observed
that inflammation was reduced
during the deep winter months. (26)
Subjects using waxed dental floss
showed significant improvements in
gingival health when compared to a
group of nonfloss users. Both
groups had a significant reduction
in debris index compared to base-
line levels during the winter, but
showed a rise in September just
before leaving Antarctica. (27)

The men at Antarctica consumed
an average of over 4,800 calories
per day, with a daily carbohydrate
increase of 55 percent and a protein
input increase of 100 percent over
their usual diet. (28) One might
burn 1,000 calories just in warm-
ing the very cold air breathed
in a day. The average calories con-
sumed dropped to about 4,000
during the dark winter months of
primarily indoor activity. (28) With
the increase in calorie consumption
and the cold stress, an increase in
vitamin requirements might be
thought necessary. Tests in 11
volunteers over an eight-month
period showed low normal values of
urine ascorbic acid and increased
excretion of nicotinamide. (29) The
ascorbic acid plasma levels were
lower in outdoor workers compared
to indoor workers. (30) However, no
gingival, mucosal, or other lesions
could be attributed solely to vitamin
deficiency.

A boxer-type mouthpiece was
tried to protect the teeth from cold
but it obstructed breathing and pre-

vented talking. Outdoor personnel
tried various means to protect their
faces from cold. As a result, at-
tempts were made to develop a cold
weather facial protection device.
(31.32)

The Lessons

All Navy personnel who volun-
teered for Deep Freeze operations
were given a battery of psychologi-
cal tests to weed out those who
might develop behavior problems
during the long period of isolation.
The extraordinary dental health
care efforts of the Navy dental offi-
cers during predeployment and
wintering-over periods also served
to make these antarctic personnel
very unique. The sudden call to
duty in cold weather of today's mili-
tary units might not find them so
well prepared. The best possible
preparation would probably be a
thorough dental inspection and
dental care of personnel before de-
parture.^.?)

Information, training, and cold
weather exercises will instill confi-
dence in being able to adapt and
perform in cold weather. (34,35)
Dental personnel should know the
rudiments of cold weather living.
They must know how to operate
field dental equipment and how to
make it perform in the cold. Knowl-
edge of shelters, heating stoves,
and generators will be indispensa-
ble to successful operations. Items
which can be damaged by freezing
must be protected during shipment
and not stored on the deck where
temperatures may be below freez-
ing. This is particularly applicable
to local anesthetic carpules. Ade-
quate heating inside a shelter may
be in the 50-55° F range, and this
could increase discomfort of in-
jected anesthetics. (12) Teeth should
be restored with cement bases.

Water will be limited in freezing
climates. This will affect scrubbing,

14

U.S. Navy Medicine

sterilizing, x-ray film washing,
drinking, personal hygiene and
camp sanitation, and fire-fighting
requirements. Personnel might be
reminded that their teeth can be
cleaned by brushes, floss, and
toothpicks without the need for
water. Air compressors and air lines
will not perform if the moisture in
the compressed air freezes in the
lines. Sewage lines or the effluent
might need to be heated. (2, 12)

Control of hemorrhage and pre-
liminary treatment of shock should
be done in the open and then the
patient should be evacuated to a
heated battalion aid station. Freez-
ing conditions may prevent use of
plasma in forward positions or
cause blood-soaked dressings to
freeze. (2) Warm water (100-110° F)
will be needed for rewarming frozen
tissues. Rapid warming should not
be continued beyond the time when
thawing is complete. Topical anes-
thetic ointments or viscous solutions
should be available for palliative
treatment of frostbite of lips and
tongue. (36)

Despite all preparations, dental
problems can be a cause of non-
effective days for military units in
the field. In one two-week training
exercise in cold weather there were
155 dental cases in an average
strength of 9,870 personnel. Most
common after that were 60 ortho-
pedic and 47 cold complaints. (37)

The conclusions to be made are
that dental support in the field is not
merely a morale factor for the
troops. The best preparation is a
high level of dental health mainte-
nance before beginning military
operations in the cold.

References

1. Frazier RG: Acclimatization and the
Effects of Cold on the Human Body as Ob-
served at Little America 10, on the United
States Antarctic Service Expedition 1939-
1941. Proc Am Phil Soc 89:249-255, 1945.

2. Eisberg HB, Owens JE: Fundamentals

of Arctic and Cold Weather Medicine and
Dentistry. NAVMED 1307. Research Divi-
sion, Bureau of Medicine and Surgery, Navy
Department, Washington, D.C., 1949.

3. Duncan RA: Dentistry in the Antarc-
tic. Br Dent J 99:395, 1955.

4. Knoedler D, Stanmeyer W: Dental
Observations Made While Wintering in
Antarctica, 1956-1957, NMRL Rep No 302. J
Dent Res 37:614-622, 1958.

5. Knoedler D: Unpublished report.

6. Stanmeyer WR: Report of the U.S.
Naval Dental Corps Assistance to the Sup-
port Force for the U.S. Participation in the
International Geophysical Year, NMRL Rep
No 283. Nav Med Res lab XVI(5), 30 Jan
1957.

7. Adams RJ, Stanmeyer WR: Antarctic
"Day" of a Naval Dentist, NMRL Rep No
325. J Am Dent Assoc 59:322-326, 1959.

8. Brown JJ: Dental Department Report
for Deep Freeze Four. Naval Submarine
Medical Center, Memorandum Rep 65-4, 25
Feb 1965.

9. Lindsay JS: Report of Operation Deep
Freeze '60 Dental Officer. Naval Medical
Research Laboratory, Memorandum Rep
61-3, 22 March 1961.

10. Allen sworth TM Jr: Dental Officer's
Report for Operation Deep Freeze Six.
'60-'61. Naval Submarine Medical Center,
Memorandum Rep 65-5, 26 Feb 1965.

11. Koss R.I: Report of Dental Officer for
Antarctic Support Activities for Operation
Deep Freeze '62. Naval Medical Research
Laboratory, Rep No 415, 8 Nov 1963.

12. Richardson WG: Personal communi-
cation.

13. Lehman PC: Personal communication.

14. Zendt RR: Personal communication.

15. Stanmeyer WR, Adams RJ: Tooth
Sensitivity During Operation Deep Freeze,
NMRL Rep No 366. Dent Prog 2:52-54, 1961.

16. Stanmeyer WR, Adams RJ: Antarctic
Stress and the Teeth, NMRL Rep No 370. J
Am Dent Assoc 63:665-670, 1961.

17. Stanmeyer WR, Adams RJ: Reduced
Oral Temperatures and Acid Production
Rates in Dental Plaque, NMRL Rep No 334. J
Dent Res 38:905-909, 1959.

18. Adams RJ, Stanmeyer WR: Effects of
Prolonged Antarctic Isolation on Oral and
Intestinal Bacteria, NMRL Rep No 335. Oral
Surg 13:117-120, 1960.

19. Esquire RG: Antarctic Isolation and
Associated Changes in Salivary Bacteria.
Naval Submarine Medical Research Labora-
tory, Rep No 812, 5 June 1975.

20. Kasenchak P. Shiller WR: Oral Acido-
genic Bacteria in the Antarctic, SMRL Rep
No 553. Milit Med 133:54-56, 1968.

21. Hawkins GR, Zipkin I: Effects of Pro-
longed Residence in the Antarctic Upon
Some Organic Constituents of Human Pa-

rotid Saliva. Proc Soc Exp Biol Med 117:888-
891, 1964.

22. Gould SS, Shiller WR: longitudinal
Study of Dental Calculus in Humans in
Antarctica. Naval Submarine Medical Cen-
ter, Rep No 512. 23 Feb 1968.

23. Magnuson LN, Shiller WR: An Eval-
uation of Dental Calculus Formation Rate
Indices in Antarctica Personnel. Naval Sub-
marine Medical Center, Rep No 600, 25 Oct
1968.

24. Adams RJ, Stanmeyer WR: The Ef-
fects of a Closely Supervised Oral Hygiene
Program Upon Oral Cleanliness, NMRL Rep
No 365. J Periodontal 31:242-245, 1960.

25. Lindsay JS, Neilsen AG: Antarctic
Environment and Gingival Health, NMRL
Rep No 396. J Periodontal 33:315-321, 1962.

26. Richardson WG, Shiller WR: A long
Term Clinical Evaluation of a Clay Contain-
ing Dentifrice in Antarctic Naval Personnel.
Naval Submarine Medical Center, Rep No
626, 7 May 1970.

27. Fisher EF, Esquire RG, Eden GT,
Mazzarella MA: Effects of Waxed Dental
Floss Inclusion in the Regimen of Oral
Hygiene of Antarctic Personnel. Naval Sub-
marine Medical Research Laboratory, Rep
No 782, 27 March 1974.

28. Adams RJ, Stanmeyer WR: Food
Requirements in the Antarctic. J Dent Res
39:687-688. 1960.

29. Adams RJ, Stanmeyer WR, Harding
RS; Antarctic Stress and Vitamin Require-
ments, NMRL Rep No 375. J Dent Med
17:36-42, 1962.

30. Perlitsh MJ, Nielsen AG, Stanmeyer
WR: Ascorbic Acid Levels and Gingival
Health in Personnel Wintering Over in
Antarctica, NMRL Rep No 359. J Dent Res
40:789-799, 1961.

31. Nielsen AG, Perlitsh MJ: Cold
Weather Facial Protection Device for Antarc-
tic personnel. Naval Medical Research Labo-
ratory, Memorandum Rep No 61-6, 14 July
1961.

32. Nielsen AG, Perlitsh MJ. Allensworth
TM : Field Testing of Facial Protective Device
in Antarctica. Naval Medical Research
Laboratory, Memorandum Rep No 63-6, 24
April 1963.

33. Lisney SJW: Dental Problems in
Antarctica. Br Dent J 141:91-92, 1976.

34. Chaney RD: Empire Glacier '78. Med-
ical Aspects of a Cold- Weather Exercise. US
Nav Med 69(8):20-23, August 1978.

35. Arthur DC: U.S. Navy Cold Weather
Medicine Training Course: A Challenge Met.
US Nav Med 70(8): 10- 13, August 1979.

36. Allensworth TM Jr: Personal com-
munication.

37. McCarroll JE, et ah Morbidity Asso-
ciated With Cold Weather Training. Milit
Med 144:680-684, 1979. □

Volume 71, April 1980

15

Sticks and Stones Can Break My Bones

Stanley J. Debiec, Jr.

"Sticks and stones can break my
bones, but names will never hart
me."

More false words were never spo-
ken. The signs of physical injuries
inflicted by "sticks and stones" or
belts, boards, cords, shoes, hands,
or feet usually heal. The emotional
scars left by the hurt of abuse and
neglect seldom do.

Child abuse and child neglect, by
whatever terms used to describe
them, permeate society. In military,
as in civilian life, abusive and ne-
glectful situations are found among
people of all occupations, all income
levels, races, colors, religions, and
both sexes. No one knows with cer-
tainty the magnitude of the abuse
problem, civilian or military, in the
United States. All we have are esti-
mates; we are talking about one
million cases of child abuse, nation-
wide a year; 2,000 deaths directly
resulting from abuse a year; 60,000
cases of physical injury a year;
6,000 cases of permanent brain
damage a year. Another estimate
we have is that it costs 5700,000 to
provide lifetime institutional care
for a severely brain damaged child.
We are talking about over $4 billion
to care for a small fraction of chil-
dren hurt every year — and that is
only the money costs we are meas-
uring.

What about the social costs? The
social costs to the victims are im-

Mr. Debiec is a social worker at the De-
partment of Pediatrics and Clinical Investiga-
tion Center, NRMC San Diego. Calif. 92134.

measurable. The social costs to each
of us as human beings are also im-
measurable. We have no way for
society to know how much we could
have benefited from these victims
who, through no fault of their own,
cannot produce to their full poten-
tial. Often they cannot produce the
material goods — a house, a car, a
job. They also have difficulty pro-
ducing a home — a happy wife or
husband, well adjusted children,
warmth, sharing, caring, love. They
cannot produce because they have
been damaged, not necessarily
brain damaged, but physically,
psychologically, mentally, and
emotionally damaged. They have
been injured early in life when they
should, could, and had every right
to be learning how great life really
could be.

Unfortunately, we tend to be
dollar oriented and have not really
developed ways to measure these
social costs. However, we do know
several things about abuse. We
know that people abused as children
are more likely to abuse their chil-
dren, that isolated people tend to
abuse, that substance abuse often
leads to child abuse, that young, in-
experienced parents under stress
use their children as objects of all
their frustrations.

We also know how to prevent
abuse. We know that the signs of
potential abuse can be recognized
early, as early as the prenatal clinic
visit, the delivery room, the nurs-
ery, the two-week or six-week well
baby visit. We know that often there
are more stressful times when
people are likely to abuse. By inter-

vening early, when we spot certain
"high risk" danger signals, we can
"plug" people into support sys-
tems. This helps reduce or elimi-
nate the times they vent their frus-
trations on their children. In other
words, we know that child abuse is
both predictable and preventable.

At NRMC San Diego, as at all
hospitals, we are making attempts
to predict and prevent abuse. We
have a long way to go but with
experience, we are improving. We
are fortunate to be part of a Family
Advocacy Program encompassing
child abuse/neglect, spouse abuse/
neglect, sexual assault and rape.
The program has two features. It is
directly funded, which means costs
are specifically planned and com-
mitted, as limited as they are. The
Family Advocacy representative has
no other duties except family advo-
cacy. In many past efforts, advocacy
personnel performed their duties on
a collateral basis. Personnel had to
find time to devote to family advo-
cacy among all other duties. At
NRMC San Diego, and a growing
number of other facilities, the
Family Advocacy representative is
assigned to a fulltime effort for
child, spouse, sexual assault, and
rape programs.

The Family Advocacy Program
(outlined in BUMEDINST 6320.57)
requires, among other efforts, the
designation of a Family Advocacy
representative and the formation of
a Family Advocacy Committee.
Among many duties, one of the
Family Advocacy representative's
functions is to help develop and
locate resources for military de-

ifi

U.S. Navy Medicine

pendent children and families,
especially those experiencing abu-
sive or neglectful situations. In
doing so, Navy regulations, state
and county laws, and the needs of
NRMC San Diego, must be matched
with the needs of the families
needing assistance. We provide
liaison with the appropriate military
and civilian agencies and resources
and coordinate the evaluation of all
reported cases in order to develop
necessary treatment and prevention
plans and programs.

The Family Advocacy Committee
acts as a body to review health care
services to dependent families,
especially those relevant to victims
of abuse, neglect, sexual assault, or
rape. It establishes guidelines for
management of individual and com-
munity problems relating to pre-
vention, protective, remedial, ther-
apeutic, and any other essential ser-
vices responsive to the needs and
welfare of Navy families. Our com-
mittee is chaired by a senior Medi-
cal Corps officer appointed by the
commanding officer (currently the
chairman, Department of Pediat-
rics) and meets monthly. Its mem-
bers are from various fields and dis-
ciplines, such as medicine, law,
American Red Cross, Alcohol Re-
habilitation Service, Naval Investi-
gative Service, Chaplain Corps,
social work, and administrative ser-
vices. This committee works closely
with the civilian social services,
police, and hospital authorities to
insure the maximum utilization of
military and civilian resources.

In addition to our three working
subcommittees (Child Abuse/
Neglect, Spouse Abuse, Sexual
Assault and Rape), we at NRMC
San Diego, have tasked the Child
Abuse/Neglect Subcommittee with
the additional role of intervention
team. The team is appointed by the
chairman of the Family Advocacy
Committee, with a purpose of pro-
viding primary medical consulta-

tion, evaluation, and treatment for
victims of child maltreatment. It is
comprised primarily of pediatricians
especially knowledgeable in the
identification and treatment of
abuse and neglect victims and also
includes a Chaplain, Nurse Corps
representative, and social worker.
The team meets weekly to discuss
and plan for all cases of reported
suspected child abuse and neglect,
and also those "grey area" cases
where no report is initially filed but
which further investigation may
indicate risk. On a weekly rotational
basis, one physician of the team is
designated the Child Abuse/Ne-
glect Subcommittee Watch. That
physician's responsibility is to be
the medical contact person for all
suspected cases of abuse and
neglect which present through any
service in the medical region.

The problem will not be solved by
only the doctor, the nurse, the so-
cial worker, or the lawyer — the list
goes on and on. We all have profes-
sional, ethical, and moral responsi-
bilities to do something. The first
step is to keep from closing our eyes
to what is going on all around us.
The second is to do something about
it. Recognize and report. Finally,
we must educate and train our-
selves to act in a nonjudgmental
manner toward abusive parents, to
be accepting of the parents or care-
takers but not of their behavior and
to show a genuine desire to help.
This is not an easy task when
dealing with a social problem that is
replete with judgment, is emotion-
ally laden, and where the desire for
retribution is often strong. We can
and do have a role in changing the
childhood refrain to:

"Sticks and stones can hurt my
bones — names, they also scar me.
The love you have, you cannot
show; without your love, I cannot
grow. Please learn how to help
me."D

Volume 71, April 1980

17

RESERVE

An Essential Partner in Naval

Readiness

LCDR S.B, Haberfcorn, MSC, USNR-R LCDR E.A. Donohue, MSC, USN

Historically, currently, and prospec-
tively the Naval Reserve constitutes
a vital capability in naval readiness.
In his concept of "One Navy," the
Chief of Naval Operations has given
strong support to the viability of our
Naval Reserve forces. Comparable
attention and support has been
given to our Navy Medical Depart-
ment Reserve components by the
Surgeon General in his emphasis on
"One Medical Department."

The purpose of this article is
briefly to outline and discuss the
officer Naval Reserve organization
and the variety of programs avail-
able. To be sure, the subject of
Naval Reserve recruitment, train-
ing, retention, and readiness has
been addressed in previous issues
of U.S. Navy Medicine. It has been
the subject of various directives as
well. Nonetheless, recent changes
in the Naval Reserve organization,
the different programs available,
and the general lack of information
on these matters among active duty
officers gives cause for an update.

All active duty officers should be
cognizant of the Naval Reserve
organization and programs. Among

LCDR Haberkorn is a Selected Reservist
with MEDCRU 613, Southfield, Mich. LCDR
Donohue is Deputy Assistant for Naval Re-
serve BUMED (MED 02D), Washington,
D.C. 20372.

those Reserve officers who return to
civilian status upon completing an
obligated tour of active duty, there
are misconceptions about military
status and further Reserve obliga-
tions. Among Regular officers on
active duty, greater familiarity with
Naval Reserve programs will enable
us to be more effective in our efforts
of personnel recruitment, training,
and retention, as well as contin-
gency planning.

Organization

Components of the Naval Reserve
are the direct responsibility of the
Chief of Naval Operations with a
chain of command as diagrammed
in Table 1 .

CNO (OP-093), the Surgeon Gen-
eral of the Navy, is the program
sponsor for the Naval Reserve's
medical program. This program is
coordinated by the Special Assistant
for Naval Reserve, Bureau of Medi-
cine and Surgery (MED 02D). The
mission of the Office of Special As-
sistant for Naval Reserve is to serve
as a central coordination point for
all aspects of the Reserve medical
program. This office informs, ad-
vises, and assists the Assistant
Chief for Professional Development
on all matters relating to the Re-
serve program, interacts with the
Contingency Planning Division to
determine Reserve requirements
and capabilities, and maintains
direct liaison with the Chief of Naval

Reserve and Reserve field activities
regarding the administration, train-
ing, and mobilization of Reserve
medical assets.

Reserve Programs

There are 40 programs in the
Naval Reserve, two of which involve
most of our medical specialty re-
servists. Program 9 — Marine Corps
Forces, provides deployable field
and air combat medical support to
insure the deployment capability of
the Fourth Marine Amphibious
Force and Air Wing. Program 32 —
Medical Program, includes Ad-
vanced Base Functional Component
(ABFC) Station Hospital Units,
Environmental Preventive Medicine
Units, Surgical Teams, Naval Re-
gional Dental Center Units, and
Medical/Dental Volunteer Training
Units. Later this year, this program
will also include newly established
Naval Regional Medical Center
Units. The role of the Naval Re-
serve, therefore, is to enhance the
active force to provide capability for
sustained combat operations afloat
and ashore.

Reserve Status and Mobilization

Delineating mobilization re-
sources, naval reservists serve in
either Ready Reserve, Standby Re-
serve, or Retired Reserve status. All
Reserve and Regular officers need
to be particularly familiar with the
structure of the Ready Reserve, the

16

U.S. Navy Medicine

CNO OP-01
Manpower

Chief of Naval Operations

CNO OP-09R
Director of Naval Reserve

Naval Reserve
Personnel Center

CNO OP-093

Surgeon General

Chief of Naval Reserve
CNAVRES

BUMED
MED-02D

Commander, Naval Reserve Readiness Command
COMNAVRESREDCOM

Commanding Officer
Naval Reserve Center

Commanding Officer
Naval Reserve Unit

Officer in Charge
Naval Reserve Unit

The solid lines indicate the line and staff relationship. The broken lines repre-
sent the liaison, coordination, and support relationship between the various
echelons.

first echelon of Reserve support in
time of mobilization.

Ready Reserve is a status in
which members are serving under a
statutory military obligation or un-
der a written Ready Reserve Agree-
ment which must be executed for an
indefinite period of time. AH offi-
cers holding a commission in the
Naval Reserve who are released
from active duty and who have not
completed their six- year statutory
military obligation, are automatical-
ly appointed in the Ready Reserve.
Officers of the Ready Reserve
(USNR-R) are, if otherwise qualified
by rank and age, eligible for assign-
ment to pay billets. They may also
receive pay and allowances for
authorized periods of active duty for
training (ACDUTRA). Ready Re-
serve officers are also eligible to be
considered for promotion with their
contemporaries. Although all Ready
reservists are liable for recall to
active duty in time of war or

national emergency, members of
the Selected Reserve (those in drill
pay status in organized Reserve
units) receive first priority. Selected
reservists constitute the principal
source of trained manpower to aug-
ment the active force. The current
authorized strength of the Selected
Reserve is 87,000 members. Those
members of the Ready Reserve not
on active duty and not participating
in the Selected Reserve are classi-
fied as Individual Ready Reservists.
Personnel in this category include
Campus Liaison officers, Seapower
Presentation teams, and members
of Volunteer Training units. Indi-
vidual Ready Reservists perform
their duties and attend drills with-
out pay. They perform ACDUTRA
with or without pay as funding per-
mits. This category of the Ready
Reserve is the second priority group
for mobilization.

Drilling Ready Reservists, pay
and nonpay, is required to main-

tain at least a 90 percent drill
attendance at regularly scheduled
drills (usually one weekend per
month) and to perform ACDUTRA
annually. If any member cannot
perform ACDUTRA during any
given year because of personal
hardship, job commitments, or be-
cause of poor health of a family
member, he or she may request a
waiver of ACDUTRA from the ap-
propriate Reserve Readiness Com-
mand.

Standby Reserve is a second Re-
serve category which consists of two
groups. The Active Standby (USNR-
SI) is comprised of reservists who
are still under a statutory military
obligation, but are not able to par-
ticipate actively in a Reserve drill
program, and those who are other-
wise eligible to participate in a
Naval Reserve training program for
retirement point credit as author-
ized by the Secretary of the Navy.
Officers who are serving in key
Federal, State, and local govern-
ment positions are also assigned to
SI status. These officers must earn
at least 12 retirement point credits
each year in order to stay in SI
status. These officers are expected
eventually to return to Ready Re-
serve status. Officers in USNR-S1
status below the rank of captain are
eligible for promotion but are not
authorized to receive pay and al-
lowances for any participation or
training duty. These members are
liable for recall to active duty on a
third priority basis without their
consent in time of war or national
emergency declared by Congress.
Inactive Standby (USNR-S2) officers
are those who have not executed a
Ready Reserve agreement upon
completion of their statutory period
of obligated service, have not re-
newed an expiring agreement when
solicited, or have failed to earn suf-
ficient retirement credit points
while in USNR-S1 status. Individ-
uals who have been in this category

Volume 71, April 1980

19

for a period of three years will be
given the option of executing a
Ready Reserve agreement, re-
questing transfer to the Retired List
if qualified, or being discharged
from the Naval Reserve. Members
in this status are not generally sub-
ject to recall to active duty.

Retired Reserve is the final cate-
gory. An officer who has completed
20 years of qualifying Federal ser-
vice may request transfer to the
Retired Reserve. He or she will re-
main in the Retired Reserve without
pay until reaching the age of 60, at
which time retired pay begins. All
members of the Retired Reserve are
liable for recall to active duty. They
are the last group of reservists to be
recalled.

Reserve Benefits

Some of the benefits of active
participation in the Naval Reserve
include eligibility for Servicemen's
Group Life Insurance and the use of
military exchanges. For the Se-
lected reservist it means additional
income commensurate with rank or
pay grade and time in service.
Medical and Dental Corps Selected
reservists can qualify for profes-
sional pay as well. For all reservists
who affiliate and participate suffi-
ciently to qualify for the Retired Re-

serve, it is an excellent retirement
program. In addition to the health
care and other benefits of retired
military personnel, the retired re-
servist at the age of 60 is eligible for
retired pay, the amount based on
rank/rate, length of service, and the
total number of retirement points
earned during military service.

Retirement Point Credits

Retirement point credits may be
earned by joining a drilling unit,
attending drills, performing ACDU-
TRA, attending approved meetings
or conferences, completing corre-
spondence courses, and recruiting,
among other duties. Ready reserv-
ists are required to earn at least 50
points each year in order for that
year to be considered as a qualifying
year for retirement and participa-
tion.

How to Join

An officer or an enlisted mem-
ber who is interested in investigat-
ing the responsibilities and benefits
of participation in the Naval Re-
serve must be prepared to take the
initiative. Unlike the very active
Naval Reserve recruiting program
for enlisted personnel, the officer
Reserve program does not have a
routine mechanism in place for con-

tacting all eligible officers for
membership in the Ready Reserve,
The officer should contact a local
Naval Reserve Recruiting Office, a
Naval Reserve Center, or the Medi-
cal Program Officer at the appropri-
ate Reserve Readiness Command.
The Medical Program Officer is
generally more expedient as he
knows precisely what opportunities
exist for officers with a medical,
dental, or allied health specialty in
the Naval Reserve. Selected Re-
serve billets (drill pay status) are
not readily obtained by persons
holding certain specialty codes. It is
therefore often beneficial for the
officer to sign a Ready Reserve
agreement, enter on a nonpay
basis, and then work through the
system to explore the possibilities of
obtaining a paid billet.

As with any job, membership in
the Naval Reserve program should
be considered carefully. It is a pro-
gram constantly in a state of flux,
reflecting the dynamic needs of the
active forces. It is also less struc-
tured than the active force, neces-
sitating a more aggressive role on
the part of each Reserve officer. By
the same token, to be in the Naval
Reserve is a privilege, a responsi-
bility, and a professional challenge
second to none. □

American Board Certifications

(Subspecialties are

indicated in parentheses)

American Board of Family Practice

American Board of Internal Medicine (con.)

CDR J.K. Lee, MC. USNR

LCDR D.R. Masys, MC, USNR

LCDR A.J. De LaMorena, MC, USNR

LT R.W. Haerr, MC, USNR

LT S.D. Condie, MC, USN

LT H. Levinsky, MC, USNR

LT R.R. HoIIoway, MC, USNR

LT P.A. Role, MC, USNR

LT W.E. Minteer III, MC, USN

LT S.C. Reichley, MC, USNR

American Board of Otolaryngology

LCDR R.M. Clayton, Jr., MC, USN

American Board of Internal Medicine

LCDR L.D. Freeman, MC, USNR

American Board of Professional Psychology

LCDR A.C. Hayes. MC. USN

LT J.D. Robinson, MSC, USNR-R

LCDR F.M. Khan. MC. USNR

(Clinical Psychology)

20

U.S. Navy Medicine

PROFESSIONAL

Mesenteric Infarction Following Exercise
in a Patient With Sickle Cell Trait

LCDR Steven R. Shackford, MC, USN LCDR Adrian L. Herren, MC, USN CDR Jerry D. Spencer, MC, USN

The clinical significance of sickle cell trait continues to
be debated. In 1970, Jones et at(l) attributed four cases
of sudden death after exercise in Army recruits with
sickle cell trait to sickle cell crises. Hypoxia, acidosis,
dehydration, increased blood viscosity, and hypercoag-
ulability were felt to have played a role in precipitating
these crises. However, after reviewing the morbidity of
sickle cell trait, Sears (10) concluded it was not possible
to assess the role of the hemoglobinopathy in such re-
ports of exertion-induced syndromes since such illesses
occur in subjects without sickle cell trait, and, although
sickling in the venous circulation has been found during
exercise, clinically significant sickling has not been
proved to be induced by physical stress. The purpose of
this report is to review the clinicopathologic findings in
a Navy recruit who expired after exercise with infarc-
tion of the small bowel associated with sickle cell trait
and to discuss the possible pathophysiology.

Patient Report

A 24-year-old recruit, in his first week of training, ar-
rived at the emergency ward of NRMC San Diego,
Calif., unconscious and with a rigid and distended
abdomen. He had been in excellent health until ap-
proximately one hour prior to admission when he com-
plained of severe abdominal pain following a 3.2 km
run. The exercise began less than two hours after
eating and lasted approximately 45 minutes. He subse-
quently collapsed and suffered a respiratory arrest. He
was revived with mouth-to-mouth resuscitation and
rushed to the hospital.

On arrival at the emergency room, he was in shock

Dr. Shackford is Director, Shock and Trauma Research Unit and
head, Trauma Branch, Surgical Service, NRMC San Diego, Calif.
92134. Dr. Herren is staff anesthesiologist and Dr. Spencer is staff
pathologist, NRMC San Diego.

with a systolic blood pressure of 60 torr. An arterial
blood gas examination revealed a pH of 7.08 and a base
deficit of 30 with a hemoglobin of 7 grams percent.
Blood was obtained for further diagnostic studies and
two large intravenous catheters were placed. He re-
ceived two units of type specific blood, three liters of
crystalloid solution, and two ampules of bicarbonate
with an improvement in systolic blood pressure to 100
torr, a pH of 7.28, and a base deficit of 10. After
tracheal intubation and placement of a nasogastric
tube, he became alert and responded to verbal com-
mands. Gastric lavage was grossly bloody and failed to
clear with iced saline. Admission laboratory tests
showed a prothrombin time of 16 seconds (control of 12
seconds), a thromboplastin time of 87 seconds (control
of 32 seconds), and a platelet count of 260,000/mm 3 .
Four units of fresh frozen plasma were administered.
Because of persistent shock and progressive abdominal
distention, a peritoneal lavage catheter was introduced.
Before introduction of the lavage fluid, the catheter was
aspirated and returned 50 cc of nonclotting blood.
Subsequent laparotomy confirmed the diagnosis of
hemoperitoneum. There was a 1 cm gastric perforation
of the greater curvature near the pylorus which was
actively bleeding. The abdominal cavity contained
grossly undigested food. There were areas of obvious
ischemia throughout the length of the small intestine.
The gastric perforation was quickly closed in two
layers. Simultaneously, it was noticed that the wound
edges began to bleed profusely as did all the patient's
mucous membranes. The patient became hypotensive
and suffered a cardiac arrest. The aorta was cross-
clamped and the chest opened for cardiac massage. Ten
additional units of blood, seven liters of crystalloid, and
six units of fresh frozen plasma were unable to restore
adequate perfusion. Further attempts at resuscitation
failed; the patient continued to hemorrhage and
expired.

Volume 71, April 1980

21

Autopsy confirmed multiple infarcts of the ileum and
jejunum and demonstrated a subcapsular hematoma of
the liver. Microscopic examination of sections of the
stomach, jejunum, and ileum showed focal serosal,
mucosal, and submucosal hemorrhage containing frag-
mented and sickled cells. Microscopic examination of
sections of the jejunum showed thrombi in the sub-
mucosal vessels. There was focal loss of the lining
epithelial cells. Many small vessels had thrombi com-
posed of normal and sickle-shaped cells (Figures 1 and
2). The spleen showed prominent congestion in the
perifollicular regions with most of the sinusoids packed
with sickle-shaped cells. The kidney also had large
numbers of sickle cell thrombi. Blood originally drawn
for cross-match procedures (prior to transfusion) was
examined with hemoglobin electrophoresis and demon-
strated quantitative levels of hemoglobin S of 40.4 per-
cent, hemoglobin A of S6.7 percent, and hemoglobin A 2
of 3 percent. Serum myoglobin was 250 ng/cc (normal
8-65 ng/cc).

Discussion

Intestinal infarction associated with sickle cell trait is
rare. McCormick(3) reviewing 120 autopsies with sickle
cell trait, noted infarction of the large and small bowel
in two necropsies, but failed to elaborate on any rela-
tionship between the infarction and the sickle cell trait.
When visceral infarction did occur, it was attributed to
hypoxia secondary to altitude or a hemoglobin S (HbS)

of greater than 40 percent. (7) The case reported herein
occurred at sea level with a HbS of 40.4 percent.

The presence of sickle cells near the infarcted areas
and the absence of other recognized etiologies suggests
a causal relationship between sickle cell trait and the
small bowel infarction in our patient. The effects of
hemorrhagic hypovolemia, recently ingested food, and
exercise on the splanchnic blood flow could have
produced a stagnant, hypoxic environment in the small
bowel leading to erythrocyte sickling, tissue infarction
and, subsequently, disseminated intravascular coagu-
lation.

No study has measured splanchnic blood flow in an
exercising man after eating. Norryd(5) noted superior
mesenteric blood flow to increase an average of 60
percent within five minutes and 113 percent within one
hour in resting subjects after eating a standard meal.
This was associated with an increase in the ratio of
superior mesenteric artery blood flow to cardiac output
from 12 to 22 percent suggesting a redistribution oi
blood flow to the splanchnic circulation presumably in
response to increased metabolic demand. However,
during exercise, Rowell(9) was able to measure a
reduction of hepatic blood flow in excess of 80 percent
in 11 healthy adults. During exercise to exhaustion,
hepatic venous oxygen content fell to 0.6 ml in three
subjects demonstrating almost complete extraction of
oxygen. Elevated hepatic venous lactate concentrations
indicative of hepatic-splanchnic hypoxia were also
noted. In another study, Rowell(#) measured a fall in

i

V

FIGURE 1. Photomicrograph of submucosal vein demonstrating thrombus com-
posed of sickled red cells.

22

U.S. Navy Medicine

*^^I

FIGURE 2. Photomicrograph of small mesenteric artery demonstrating sickled red
cells.

splanchnic blood flow from an average resting value of
1.61 1/min to values ranging from 820 to 390 ml/min
during moderate to severe upright exercise. In addi-
tion, he found a reduction of 35 percent in splanchnic
blood volume. Such decreases in splanchnic volume
and flow coupled with increased demand and maximal
oxygen extraction would provide an hypoxic and acidic
environment which could have led to sickling in our pa-
tient.

Rickels and O'Leary(fJ) consider the sickled erythro-
cytes as the primary factor in initiating vascular occlu-
sion by increasing blood viscosity and promoting
sludging in the capillaries and small venous channels.
The anoxia in local areas of the microvasculature may
result in endothelial disruption and exposure of suben-
dothelial tissue, such as collagen, to the circulating
blood. The exposed collagen may then initiate throm-
bosis either by promoting adhesion and subsequent
aggregation of platelets or by activating Hageman
factor. These authors also noted that disturbances in
reticuloendothelial function may occur in patients with
sickle cell disease. These patients are at a greater
danger of developing disseminated intravascular coag-
ulation (DIC) because the liver and spleen may be
unable to remove particulate thromboplastin. The asso-
ciation of DIC with exercise-induced syndromes or sud-
den death in sickle cell trait has been well documented.
(2.4,11)

The diagnosis of mesenteric infarction should be con-
sidered in those patients with sickle cell trait presenting
with an acute surgical abdomen. Suspicion should be

heightened if HbS concentration is greater than 40 per-
cent, abdominal pain occurs with postprandial exercise,
and postprandial abdominal pain occurs in unaccli-
mated individuals at high altitudes.

References

1. Jones SR, Binder RA, Donowho EM Jr: Sudden Death in
Sickle-Cell Trait. N Engl J Med 282:325-327, 1970.

2. Koppes GM, Daly JJ, Coltman CA, Butkus DE: Exertion-
Induced Rhabdomyolysis With Acute Renal Failure and Disseminated
Intravascular Coagulation in Sickle Cell Trait. Am J Med 63:313-317,
1977.

3. McCormick WF: Abnormal Hemoglobins. II. The Pathology of
Sickle Cell Trait. Am J Med Sci 329-335, March 1961.

4. Mease AD, Longo DL, Hakami N: Sicklemia and Unexpected
Death in Sickle Cell Trait: Observations of Five Cases. Milk Med 470-
473, July 1976.

5. Norryd C, Dencker CN, Lunderquist A, Olin T, Tylen U: Supe-
rior Mesenteric Blood Flow During Digestion in Man. Acta Chir
Scand 141:197-202, 1975.

6. Rickles FR, O'Leary DS: Role of Coagulation System in Patho-
physiology of Sickle Cell Disease. Arch Intern Med 133:635-641,
1974.

7. Rotter R, Luttgens WF, Peterson WL, et al: Splenic Infarction
in Sicklemia During Flight. Pathogenesis, Hemoglobin Analysis and
Clinical Features in Six Cases. Ann Intern Med 44:257-270, 1956.

8. Rowell LB: Human Cardiovascular Adjustments to Exercise
and Thermal Stress. Physiol Rev 54:75-159, 1974.

9. Rowell LB, Brengelmann GL, Blackmon JR, Twiss RD,
Kusumi F: Splanchnic Blood Flow and Metabolism in Heat-Stress
Man. J Appl Physiol 24:475-484. 1968.

10. Sears DA: The Morbidity of Sickle Cell Trait: A Review of the
Literature. Am J Med 64:1021-1036, 1978.

1 1 . Zimmerman J, Mummert K, Granatir R, Cioffi R: Sickle Crisis
Precipitated by Exercise Rhabdomyolysis in a Patient With Sickle
Cell Trait: Case Report. Milit Med 313-315. April 1974. G

Volume 71, April 1980

23

Immunization Survey in a
Military Practice

LCDR William W. Burns, MC, USN

Much concern has been expressed over the immuniza-
tion status of children in the United States. (7) The
American Academy of Pediatrics, as part of its program
during the International Year of the Child, adopted
the position that "all children should be immunized
against the preventable infectious diseases for which
there are recommended immunization procedures." (2)
Audits of immunization completeness have been per-
formed previously in private practices and public health
department clinics by means of chart reviews. (3,4) The
author undertook the present survey to evaluate the
completeness among patients seen in a military
pediatric practice.

Patients and Methods

The pediatricians at this institution care for military
dependents from birth to age 17. The immunization
status of all patients seen by the author during a one-
month period (7 May-7 June 1979) was determined by
parent/child interview and review of the child's medi-
cal record at the initial contact. Completeness of im-
munizations was judged against the current recom-

mended schedule. (5) A tally sheet was kept for dif-
ferent age groups (0-23 months, 2-4 years, 5-9 years,
10-14 years, and 15+ years). Those whose total medical
care had been given at military medical facilities were
differentiated from those whose care had been given in
part at other than military facilities (Table 1). A qualita-
tive assessment was made of the compliance with
recommended immunization schedules. Three large
groups were tallied — those with complete immuniza-
tions, those lacking one to two inoculations for age, and
those lacking three or more.

Results and Discussion

The overall completeness of the survey group (all
ages), as shown in the table, was 83 percent. Seventeen
percent were behind 1-2 doses of vaccine. No children
were behind more than two doses.

Seventy-nine percent of the patients received total
military care, and of this group 84 percent had up-to-
date immunizations. Twenty-one percent of the
patients received partial military medical care, and of
this group 77 percent had up-to-date immunizations.

TABLE 1. Completeness of Immunization Schedules by Age and Source of Medical Care

Total

Partial

Military Care

Military Care

Total

Age

Complete Incomplete

Complete Incomplete

Complete

Incomplete

0-23 months

82 16

11

93

H

2-4 years

32 2

9 1

41

a

5-9 years

40 1

11 2

51

3

10-14 years

21 3

9 5

30

8

15 +

5 12

4 5

9

»

Total

180 34

44 13

224

«

Dr. Burns is staff pediatrician at the Naval Aerospace and Regional
Medical Center, Pensaeola, Fla. 32512.

24

U.S. Navy Medicine

This difference was not statistically significant {by chi-
square test).

An interesting finding was that 35 percent (9 of 26) of
the older adolescents {age 15 + ) were inadequately im-
munized at a time when measles prevalence was noted
to be higher in Florida than overall in the United States.
(7) For the most part, this age group had received
killed-virus measles vaccine, or had received live-virus
measles vaccine prior to 12 months of age. In either
situation, reimmunization should have been performed
in accordance with the current recommendations. (6)

Many infants found to be behind on immunizations
had had routine inoculations deferred at "well-baby"
examinations due to intercurrent febrile illness, not due
to parental neglect.

All parents of patients found to be delinquent in ob-
taining immunizations were counseled to update their
immunizations.

It was the author's impression prior to conducting
this survey that the level of immunization among mili-

tary dependents is relatively high, and this impression
was confirmed. This level compares favorably with the
level found among two-year-olds in a chart audit by
Bloom. (4) These reassuring data reflect good availabil-
ity of this important preventive measure and good com-
pliance among military dependents,

References

1. Center for Disease Control: Fact Sheet on Childhood Immuni-
zation. Am J Dis Child 132:435, 1978.

2. Kendig EL Jr: Working Toward Our Goals. American Acad-
emy of Pediatrics, News and Comment p 8, April 1979.

3. McDaniel DB, Patton EW, and Mather JA: Immunization Ac-
tivities of Private-Practice Physicians: A Record Audit. Pediatrics 56:
504-507, 1975.

4. Bloom JE: Results of an Immunization Audit. Pediatrics 60:
547, 1977.

5. American Academy of Pediatrics: Report of the Committee on
Infectious Diseases, 18th Edition, p 3, 1977.

6. Center for Disease Control: Measles Prevention. Morb Mart
Wkfy Rep 27:427-437, 1978.

7. Center for Disease Control: Measles — United States, First 26
Weeks (1979). Morb Mort Wkly Rep 28:349-350, 1979. D

CAT Scanner at Oakland

A new General Electric 8800 Com-
puterized Axial Tomography (CAT)
scanner, capable of producing high
resolution images of both head and
body, and purported to be one of the
most technologically advanced mod-
els available in the nation, is now in
full operation at NRMC Oakland.

CAPT Robert L. Houts, Chairman
of Radiology Service, in reporting on
the equipment's capability of pro-
ducing "exquisitely clear anatomic
images beyond the conventional
radiograph." said that the CAT
scanner is able to detect subtle dif-
ferences in human tissue and to pro-
duce lifelike images never before
achieved.

"It is able to show distortions of
normal anatomy such as tumors and
give an idea of their pathological
nature by using x-rays and highly
advanced computers to assimilate
many small pieces of information,"
he explained. (A computed tomogra-
phy scan is developed from multiple
x-ray absorption measurements and
is actually a computer reconstruction
of a slice or body section.)

The scanner's use on the head al-
lows radiologists to distinguish be-
tween gray and white matter of the
brain, thereby making it possible to
pinpoint specific location and diag-
nose the type of problem.

*

hi

j.

A Navy corpsman plays the role of a
patient ready to undergo examina-
tion by a new CAT scanner at NRMC
Oakland.

In addition to the scanner itself,
the system is equipped with a radio-
therapy planning program which can
be used to set up treatment plans for
cancer victims.

With its most recent acquisition of
the accessory Scout View Package,
Oakland becomes the first site in the
entire western United States to have
this precision instrument, which al-
lows great detail in studies of
localized areas of interest within a
patient's body. Because of its preci-
sion, the Scout View limits the total
number of scans necessary for diag-
nostic purposes, thereby reducing
radiation exposure to the patient.

Basic components of a CAT scan-
ner are a patient handling table,
scanning gantry (which is a movable
frame containing the collimated
x-ray source and detector), data
acquisition electronics, x-ray genera-
tor, computer, and the operator and
viewing consoles. Data acquisition
and image reconstruction may pro-
ceed simultaneously through use of
the time-sharing capabilities of the
computer.

History of the development of the
scanners reaches back to 1967, when
Godfrey Hounsfield from the Central
Research Laboratories of EMI, Ltd.,
in England, undertook gamma and
x-ray experiments in tomographic
reconstruction. His examination of a
preserved, diseased human brain,
with cooperation of the British De-
partment of Health and Social Secu-
rity, and Dr. James Ambrose, Con-
sultant Radiologist at Atkinson Mor-
ley's Hospital, revealed dramatic re-
sults and led to the development of
the first clinically useful CT equip-
ment.

They were able to clearly see the
cause of disease — a brain tumor —
convincingly isolated by the tomo-
graphic reconstruction, and could
additionally distinguish between the
gray and white matter of the
brain. □

the

Volume 71. April 1980

26

Serendipitous Discovery of Artificial
PositiveWeil-Felix Reaction Used in
"Private Immunological War"

E.S. Lazowski

S. Matulewicz

In 1916, during the epidemic of the classic, louse-borne
typhus (epidemic typhus or jail fever) in Southeast
Poland, Edmund Weil, a Pole, and Arthur Felix, a
Czech, found Proteus in urine of patients with typhus.
Agglutinins to certain Proteus were also found in the
serum of these same patients.

This bacillus strain was termed ' Proteus X, ' ' and the
specific strain of typhus became "OX-19." It was also
discovered that Proteus is agglutinated not only by the
patient's serum, but also by sera of others suffering
from typhus. The strain was agglutinated to a titer of
from 1:50 to 1:50,000 by typhus sera and never 1:25 by
the serum of nontyphus patients. (/) At this time, Felix
was even of the opinion that Proteus and Rickettsia
prowazeki (named after the American Howard Ricketts
and the Austrian Stanislaus von Prowazeki), which
caused typhus, were genetically related. (2) As we
know, this was not true and Proteus is not an etiological
agent in epidemic typhus.

Since 1916, Weil-Felix's reaction has remained a
simple and useful diagnostic test for epidemic typhus
and is valid diagnostic evidence in the presence of
clinical symptoms. (/) During World War II, the test
was used as a confirmation of typhus fever by Germans.

The Weil-Felix reaction is still in common use as a
screening test and is simple and economical. Comple-
ment fixation methods for diagnosis of rickettsial
disease are more specific and satisfactory, but they are
laborious and expensive. Rickettsial agglutination and
hemagglutination procedures are also available but are

Reprinted from the American Society for Microbiology News, June
1977. Dr. Lazowski is an assistant professor at Northwestern Univer-
sity Children's Hospital School, Chicago, 111. 60608. Dr. Matulewicz is
a professor at the National University, Kinshasa, Republic of Zaire.

not practical for the clinical laboratory. (3)

In fact, the Weil-Felix reaction is not specific in the
diagnosis of epidemic typhus. False-positive reactions
may occur with Proteus urinary tract infections,
leptospirosis, Borrelia infections, and severe liver dis-
eases. (J) Antibiotics, as well as aging of commercially
available antigen, may suppress or delay antibody pro-
duction.

In addition to epidemic typhus, murine typhus and
Rocky Mountain spotted fever are also linked with
Proteus antibody formation, but they are not known in
Europe. False negative reactions may occur in patients
previously vaccinated against epidemic typhus and who
later develop natural infections. (3)

The Weil-Felix reaction is based on cross-reaction
and is not related to rickettsial antigens at all.
Antibodies formed in the course of certain rickettsial
diseases react with polysaccharide "O" antigen of
certain strains of Proteus "X" bacteria. (2) The original
strain of Proteus used by Weil-Felix was strain OX-19,
which was found to be the most specific for epidemic
typhus. This strain, killed by formalin, has been used
ever since as the reagent for the Weil-Felix reaction.

Agglutinins usually appear in seven days after the
onset of the disease, increasing to a maximum in about
15 days, and then decreasing slowly over several
months. Generally, titers of 1:80 are suspicious and
titers of 1:160 are significant. (4) A fourfold rise of
agglutinin titer is considered diagnostic for active in-
fections. (5)

One of us (Dr. Matulewicz) reasoned that if in vitro
Proteus suspension agglutinated the serum of a person
with epidemic typhus, perhaps an injection of this sus-
pension in a healthy person might cause his serum to
agglutinate the Proteus OX-19. (6)

U.S. Navy Medicine

The Proteus OX-19 in suspension used for the Weil-
Felix reaction was treated with formalin. The amount of
formalin in the suspension was about the same as in the
typhoid vaccine commonly used. Theoretically, the sus-
pension seemed to be relatively as safe as an injection
of typhoid vaccine. Would such an injection convert the
serum of a healthy person to Weil-Felix positive?

During the German occupation of Poland in World
War II, the Germans realized their plan of extermina-
tion of Jews and Poles as "racially inferior groups."
Hitler's biological materialism disregarded all ethical
and humanitarian principles. As a result, during the six
years of occupation, about one-fifth of the population of
Poland was murdered in mass executions, prisons, and
concentration camps or died as a consequence of other
misfortunes of occupation. (7,8) Because the Germans
needed cheap labor for war industry and agriculture,
they transported thousands of Poles and forced them
into slavery in Germany.

At this time, Polish physicians were confronted with
a special task — not only to prevent diseases and treat
sick people, but also to defend their lives and those of
their countrymen.

In the General Government (as Germans called oc-
cupied Poland), because of deteriorating sanitary con-
ditions, epidemic typhus, or the "disease of human
misery," appeared. Hospitals became overcrowded,
and the majority of patients were treated at home.
When many cases were reported from an area, it was
declared by the German Public Health Authority to be
an "epidemic area." This situation produced some
advantages for the people, because the Germans were
inclined to avoid such territories and the population was
relatively free from atrocities.

Epidemic typhus had not been reported in Germany
for more than 25 years before World War II. (5) The im-
munological resistance of the Germans was lower and
mortality was higher in respect to epidemic typhus than
was that of Poles and Russians. Germans were afraid of
spreading typhus among their own population.

A strong ordinance in the General Government re-
quired physicians to report to German health authori-
ties all suspected and confirmed cases of epidemic
typhus. For diagnostic purposes, samples of blood were
mailed to German-controlled state laboratories. In the
case of a positive result, laboratories were obliged to
notify the German authorities first and then the physi-
cian who provided the specimen.

On one occasion a Polish laborer, deported to
Germany, was granted a 14-day leave to visit his family
in the "General Government." If he did not return to
Germany on time, he would be followed by the police,
and, if he was not found, his whole family would be

arrested and transported to a concentration camp. Only
a serious disease, verified by a physician's certificate,
could justify the prolongation of leave or absence. Any
"irregularity" in such a certificate would be extremely
dangerous for the physician as well as for the patient.

This same laborer on leave of absence was ready to
do anything, including committing suicide, to escape
the misery of slavery in Germany. He became the first
volunteer to receive an injection of Proteus OX-19 sus-
pension. He and the physician were fully aware of the
danger if the Germans discovered the experiment. The
volunteer was also informed that he would be the first
to get the injection and, in spite of theoretical safety,
some unpredicted reaction could occur.

This laborer received the first intramuscular injection
of 1 cc of laboratory suspension of Proteus OX-19 (ad-
ministered by Dr. Matulewicz. The Weil-Felix reaction
was found to be positive with a titer of 1:500. This
person's blood was then mailed to the German State
laboratory at once, and soon the telegram arrived with
an official result: "Weil-Felix positive." (6)

The telegram was presented to local German authori-
ties, and the volunteer was officially released from his
duties in Germany. In addition, he and all of his family
in contact with him were excluded from future deten-
tion. The Germans were afraid of transferring
"infected" lice during the incubation period.

It immediately became clear (to Dr. Lazowski) that
the artificial Weil-Felix could be used as a form of
defense against the policies of the German occupation
government. In top secrecy, we started to inject
selected patients with any suggestion of symptoms to
epidemic typhus with a suspension of Proteus OX-19 as
"protein stimulation therapy."

Intramuscular injections of protein suspension were
widely used during the last decade before World War
II. It was believed that in this way, one could stimulate
the general immunological resistance of the patient.
Autohemotherapy, some vaccines, and even special
pharmaceutical preparations (e.g., Omnadin) were
used. So we also used our suspension of killed Proteus
as a vaccine to build up general immunological re-
sistance.

The number of injections and cases were strictly con-
trolled by us according to classic general rules of
epidemics — increasing during the winter, diminishing
during the spring, and increasing again in the fall.

More and more positive Weil-Felix reactions were
reported by German-controlled laboratories to German
authorities and confirmed by our reports. Soon the
number of reported cases was sufficiently large to
declare the area of our practice (about a dozen villages)
an "epidemic area," with relative freedom from op-

Volume 71, April 1980

27

pression.

After one year, one of us (Dr. Matulewicz) moved
away from the area. The "private immunological war"
was continued (by Dr. Lazowski) at an enormous risk for
the next two years. During this period, a medical de-
tachment of the German army made an inspection of
our "epidemic area" on the basis of information sup-
plied by a collaborator. The greatest danger (for Dr.
Lazowski) was the actual clinical examination of pa-
tients by German doctors. The logical assumption for
the Germans was that a Polish physician could use the
blood from one typhus patient for many other reported
cases. However, fearing infestation by "infected lice,"
the Germans limited themselves to taking samples for
Weil-Felix reaction only in their own special labora-
tories. Their findings, of course, were positive because
the reaction was a true biological one, created by an
artificial method, not previously known.

Our "private immunological war" gave us a deep

satisfaction because we knew that we had saved the
lives of people who would otherwise have been killed,
simply because they were Jews or Poles.

References

1. Wilson GS, Miles AA: Principles of Bacteriology and Immu-
nity. Baltimore, Williams & Wilkins Co. 1964.

2. Davis BD, et al: Microbiology, ed 2. Hagerstown, Harper &
Row, 1973.

3. Davidson I, Henry JB (eds): Clinical Diagnosis by Laboratory
Methods. Todd-Sanford, Philadelphia. Saunders, 1974.

4. Ravel R: Clinical Laboratory Medicine, ed 2. Chicago, Year
Book Medical Publishers Inc. 1973.

5. Bedson S, el al: Virus and Rickettsial Diseases of Mart, ed 4.
London, Edward Arnold Ltd, 1967.

6. Matulewicz S: Experience During Epidemy of Typhus Fever in
Poland Occupied by Germans, 1939-45 (unpublished data).

7. Geysztor A, Herbst S, Lesniodarski B: History, In Poland.
Warsaw, Polania Pub, 1965, chap 14.

8. Biologiczne Straty Narodu, In Informator Polski. London, June
1945. p93. □

:

BUMED SITREP

PROJECT REEP

The Chief of Naval Operations stated that reten-
tion of personnel is his number one goal. To assist
the CNO in achieving that goal, the Medical Depart-
ment published BUMED Instruction 1000.2 on 29
Feb 1980. The instruction implements Project REEP
(Retain Each Eligible Person); BUMED's retention
program which is applicable to each member of the
Medical Department. Project REEP addresses the
following goals that need improvement:

Honesty/Integrity of Recruiting Programs
Quality of Orientation Programs
Sponsor Program
Retention Counseling
Communication

Career Planning and Assignments
Interface with Navy/ Marine Corps Line
Recognition of Personnel
Quality Administrative Support
Duties Out of Specialty
• Ancillary Support

All Medical Department personnel are required to
implement this instruction and commanding officers
must submit a quarterly report to BUMED (MED 02)
in the prescribed format. This report provides

BUMED personnel with the information needed to
assist commanding officers in achieving their reten-
tion goals.

Each senior Medical Department leader is asked
to support fully the requirements and suggestions of
Project REEP. The results will be improved reten-
tion, increasingly higher morale, and a stable and
highly professional Medical Department.

U.S. NAVY MEDICINE MAGAZINE

Several activities have reported that they are
receiving copies of U.S. Navy Medicine on a timely
basis. Some problems originate at the Naval Publi-
cations and Forms Center, Philadelphia, the central
distributer. That situation is now being corrected. To
insure delivery locally, commanders are urged to
monitor their activity's mailrooms. U.S. Navy Medi-
cine is to be distributed, one copy for each Medical,
Dental, Medical Service, and Nurse Corps officer
and one copy for every 10 enlisted Medical Depart-
ment members. For BUMED to determine the
efficacy of new controls and distribution from Phila-
delphia, each activity should notify via phone or
letter BUMED (MED 001 D) upon receipt of the
March and April issues. Autovon 294-4253.

28

U.S. Navy Medicine

NOTES & ANNOUNCEMENTS

INMEMORIAM

CAPT James Lawrence Glass, MC, USNR, who was a
member of the surgical staff at NRMC Jacksonville,
Fla., died 5 March 1980, while on leave in Idaho.

A native of Memphis, Tenn., Dr. Glass entered the
Navy in 1955 as an intern at the Naval Hospital Phila-
delphia, Pa. He then received his general surgery
training as a resident at Naval Hospital San Diego,
Calif.

After a brief tour of duty at Naval Hospital Memphis,
Tenn., he returned to San Diego as a thoracic surgical
resident until 1960, when he was deployed aboard USS
Repose (AH-16) off the coast of Vietnam. He then
served as a thoracic surgeon at Oakland Naval Hospital
and NRMC Camp Pendleton, Calif., where he left the
Navy and pursued a career as a civilian cardiac surgeon
in San Diego until 1979. He returned to active duty and
was stationed at NRMC Jacksonville.

Dr. Glass was a member of the American Medical
Association, the California Medical Association, and
was certified by the American Board of Surgery, Ameri-
can Board of Thoracic Surgery, American College of
Chest Physicians, and the American College of Cardiol-
ogy. He was awarded the Navy Unit Commendation,
National Defense Service Medal, Vietnam Service
Medal, and the Republic of Vietnam Campaign Medal.

MSC OFFICER SURVEY

This May, Medical Service Corps officers will have
an opportunity to participate in a Corps-wide survey of
attitudes, opinions, and perceptions about their jobs,
their professions, their roles as officers, and their naval
service careers in general. The purpose of the survey is
to develop information for use in career planning, de-
velopment, and counseling with MSC officers of all
specialties.

Effective career planning requires that we meet
organizational requirements. The definition and logic of
those requirements is currently a matter of review by
the Medical Service Corps Division, BUMED through
various billet analyses. But effective career planning
also requires that we know something about the needs,
aspirations, and values of the organizational members
— our MSC officers in this instance. Consequently, your
thoughts about career matters are not only of interest to

Medical Department planners; they are vital. Your
participation in the forthcoming survey, therefore, is of
the greatest importance.

Should you have questions about the study, the co-
principal investigators can serve as points of contact.
They are LCDR Paul T. Bruder, MSC, USN, Naval
School of Health Sciences, Bethesda, Md. (Autovon:
295-1467) and LT Mark Butler, MSC, USN, Naval
Health Research Center, San Diego, Calif. (Autovon:
933-2061).

MSC FULL-TIME TRAINING AT USUHS

MSC officers who are considering full-time training
for FY81 are beginning to get their requests in order
and making application for admission to one or more
institutions of higher learning. Officers interested in
pursuing master' s or doctoral studies in anatomy, bio-
chemistry, medical psychology, microbiology, pharma-
cology, or physiology are invited to explore those pro-
grams offered by the Uniformed Services University of
the Health Sciences (USUHS). The USUHS offers uni-
que graduate and postgraduate opportunities. This not
only stems from its affiliation with NNMC, Walter Reed
Army Medical Center, the National Institutes of
Health, the National Library of Medicine, the Armed
Forces Institute of Pathology, and the Armed Forces
Radiology Research Institute, but also from its em-
phasis on the support role of health sciences in the
military environment.

Requests for further information should be addressed
to: Dr. John W. Bullard, Assistant Dean for Graduate
Education, Uniformed Services University of the Health
Sciences, 4301 Jones Bridge Road, Bethesda, Md.
20014.

WANTED— ARTICLES AND PHOTOS

U.S. Na\y Medicine has always encouraged our
readers to submit articles in the areas of their ex-
pertise or experience. We are especially looking
for articles relating to medical or dental research
topics, surgical procedures, and office treatment
techniques in any dental or medical specialty. We
would also like good black and white photos to
accompany those manuscripts.

Volume 71, April 1980

29

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